Eli's Rehab Report

Question: On the same day, we provided physical therapy to a patient with referrals from two different physicians. Both referrals had two different onset dates and diagnoses. We kept two different account numbers but have received denials for procedures to one account due to duplication. I have appealed once on a separate date of service but have yet to hear back from them. Our carrier is NHIC. Do you have any suggestions? 


Georgia subscriber

Answer: Assuming you are billing the Medicare carrier on two separate 1500 claim forms, you are billing and submitting the claim forms correctly.

According to CMS Pub 100-04, Chapter 26, "when a claim involves multiple referring and/or ordering physicians, a separate Form CMS-1500 shall be used for each ordering/referring physician." But this may still cause your Medicare carrier to deny one of your claims as a duplicate, even though it is not. You should call your Medicare carrier and explain your situation. This will usually resolve the problem.

Note: Effective Nov. 29, 2006, CMS has a new process to address this exact problem. This is called a "re-opening," and one of the situations that qualifies for the re-opening process is a denial in which the party believes the Medicare contractor incorrectly identified the claim as a duplicate. If you submit claims to a Medicare carrier, you can complete this re-opening over the telephone. To read more about the re-opening process, go to www.cms.hhs.gov/transmittals/downloads/R1069CP.pdf.